Abstract

This study describes the case of a 55-year-old male with painful peripheral neuropathy, which was severely hindering his quality of life. Despite numerous pharmaceutical interventions, his pain was poorly managed. Electroacupuncture and a gluten-free diet were successfully utilized, resulting in pain resolution and a return of patient functionality.

Introduction

Peripheral neuropathy is a poorly understood chronic pain condition resulting from the demyelination and degradation of axonal nerve fibers. Neuropathies can be the result of toxic exposures, metabolic conditions, traumatic injuries, or infections.1 In some instances, the etiology cannot be elucidated. A neuropathy is commonly treated with a variety of medications, eg, non-steroidal antiinflammatory drugs, opioids, anticonvulsants, and antidepressants.2 The success of these pharmacologic interventions varies and complete cure is not expected. Recently, there has been growing concern about the abuse potential of opioid medication. With this growing recognition, a need for alternative solutions for chronic pain, including neuropathic pain types, is particularly relevant. This article will present the case of B.F., a 55-year-old male who presented with a case of peripheral neuropathy that was resolved with dietary gluten elimination and electroacupuncture treatments.

Case Presentation

B.F., a 55-year-old male, presented with classic paraesthesia symptoms of neuropathic pain: burning, tingling, and, as he described it, “biting” sensations in his feet, jaw, and fingers bilaterally. The pain began approximately 2.5 years prior to our first meeting in May, 2012. Tests for vitamin B12 deficiency, blood glucose, inflammation, and HIV were all unremarkable. B.F. did test positive for low serum testosterone, which was treated with intramuscular injections. Physical exam revealed hypesthesia bilaterally that was particularly focused on the medial aspect of the first toes. MRI, ultrasound, and circulatory imaging studies revealed only mild arthritis of the first MCP joint. A neurologist conducted electrophysiological testing, and B.F. was diagnosed with peripheral neuropathy.

B.F. had a history of alcoholism and working with toxic materials in the heating, ventilating, and cooling industry (HVAC). Alcohol abuse is an independent risk factor for peripheral neuropathy.3 B.F. was prescribed varying combinations of medications over a 2-year duration that included: allopurinol, naproxen, colchicine, prednisone, tramadol, gabapentin, morphine, pregabalin, ketorolac, nortriptyline, duloxetine, hydromorphone, and nabilone. B.F. was also obtaining morphine, methadone, marijuana, oxycontin, and occasionally cocaine from street sources to supplement his pain medication. B.F. expressed frustration with the medications, as he often experienced fatigue, dysphoria, impaired cognitive function and withdrawal effects, while his pain continued to increase in intensity.

Management and Care

B.F. commenced weekly acupuncture treatments. Point selection was based on a combination of his Traditional Chinese Medicine diagnosis and areas of maximal pain. Common points used were LI11, SJ5, LR2, SP2, SP6, GB40 and “well points” on the feet, which are the most distal points on each acupuncture channel. When treatment initially commenced, with a frequency of one pulse per second, the current level was at 24 mA (milliamps). After 10 months of treatment, the current level was reduced to 16 mA as his paresthesia began to heal. The frequency remained unchanged. Neuropathic pain was severely hindering B.F.’s activities of daily living. Activities like playing guitar, sustained walking and standing, and working as a HVAC technician were impossible when he first presented to me. His day-to-day functionality was used as a marker for treatment success, as well as his subjective rating of pain intensity.

After 1 month of electroacupuncture treatment, his symptoms, by his account, had improved by 75%. When B.F. started treatment, a folded towel would have to be placed on the floor because it was extremely painful for his feet to make contact with a hard surface. After 4 treatments, this measure was no longer necessary. After 5 months of treatment, B.F. was able to reduce treatments to biweekly.

Dietary change occurred slowly over the course of months, beginning with increasing his intake of plant-based foods, and progressing to elimination of refined sugar and gluten after 2 months. In the case of B.F., he did not manifest gastrointestinal symptoms characteristic of gluten-based enteropathies and he tested negative for anti-gliadin antibodies. However, by his own account, pain symptoms improved by 90% when he eliminated gluten. Currently, when B.F. consumes gluten in any significant quantity, he notes an almost immediate exacerbation of his foot neuropathy.

Medication weaning was done under B.F.’s own initiative and to date he has been able to eliminate all of the aforementioned medications except methadone. Currently he is participating in a methadone harm-reduction program to safely wean him from high-dose opioid medication. He uses marijuana sporadically and is a member of a marijuana compassion center. B.F. has resumed modified work duties and the day-to-day activities he enjoys.

Discussion

Peripheral neuropathy is a poorly understood but common manifestation of gluten sensitivity and celiac disease.4,5 The case of B.F. also suggests that even without the classic serum markers for celiac, adopting a gluten-free diet can assist in nerve pain resolution. Any patient presenting with bilateral sensory peripheral neuropathy should be screened for anti-gliadin antibodies. Neuropathy symptoms can precede or exist without gastrointestinal symptoms. While it is common for anti-neuronal antibodies to be present in celiac patients, serum measurements of antibodies do not directly correlate to subjective patient experience of nerve pain.6

Anti-gliadin IgG and IgA antibodies cross-react with synapsin-1, a ubiquitous phosphoprotein present on both central and peripheral nervous cells. Synapsin-1 is largely responsible for forming and regulating synaptic vesicles.7 Autopsy studies of patients with peripheral neuropathy and gluten sensitivity show destruction of the dorsal root ganglia and peripheral spinal cord columns. Malabsorption of micronutrients may also contribute to derangement of the nervous system in the celiac patient population.5 As gluten-free diets have notoriously low patient compliance, it is important that the attending ND provides dietary planning guidelines that support strict adherence and patient success.

Thanks to the research of Bruce Pomeranz, we know that acupuncture needling has the ability to manipulate nociceptors, proprioceptors and autonomic nerve pathways. Pain relief starts with a cascade of enkephalins, dynorphins and endorphins in the spine, midbrain and hypothalamus-pituitary region. In response to these chemicals, serotonin, norepinepherine, monoamines, and endorphins are released, decreasing substance P and the subsequent pain response. Electroacupuncture serves to add additional needle stimulation.8 Cha et al. (2010) found that electroacupuncture reduces nitric oxide synthase, thereby decreasing nerve allodyina.9 There are a number of research studies that support the use of acupuncture and electroacupuncture as a means of treating neuropathic pain of various etiologies. The most commonly studied neuropathies are those that are chemotherapy-induced, HIV-related, and diabetic.10,11,12,13

Conclusion

While case studies do not provide generalizable data, gluten elimination and electroacupuncture each have their own bodies of research to support their use as treatments for peripheral neuropathy. A limitation of this case, from a research perspective, is that dietary improvement and electroacupuncture were initiated simultaneously, making it difficult to isolate the individual effect of each treatment modality. However, B.F. was able to communicate some distinction. He noted that pain management was the best immediately after acupuncture and it would wane until his subsequent appointment. Furthermore, if B.F. was not stringent about his gluten avoidance, he would experience transient pain flare-ups. While this is a limitation in terms of research, in a clinical setting it is positive that NDs have numerous modalities that work synergistically to achieve patient healing.

Lydia Thurton, ND, graduated from the Canadian College of Naturopathic Medicine in 2010. Lydia maintains a general family practice in Pickering, Ontario and is also the naturopathic physician for the AIDS Committee of Durham Region. Her special area of focus is on African-Canadian, and Caribbean patient populations and she is a regular contributor to the Toronto Caribbean News.

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